Ontario Blue Cross Quote Request

Please provide the information below to request a quote for Ontario Blue Cross.

Please note that you must apply for family coverage if your family does not have alternative coverage through your spouse or another source.

Name * First Last
Email *
Date of Birth * / MM / DD YYYY
Do you smoke? *
Yes No
Type of Coverage *
Single Family
Family Coverage Information

If you choose Family coverage, please complete the section below, if you choose Single please skip and click "Continue" below.

Dependent children are eligible if they are:
under 21 and not working full-time
- or -
under 25 and enrolled as a full-time student at an accredited post-secondary institution
Spouse Name First Last
Spouse Date of Birth / MM / DD YYYY
Do they smoke?
Yes No
Number of Eligible Dependent Children

Ontario Blue Cross Quote Request

Ontario Blue Cross Quote Request

Family Coverage Information